Problem Gambling: Prevalence, Screening, Assessment and Intervention

Problem Gambling: Prevalence, Screening, Assessment and Intervention QCA Professional Development 1 August 2014 Jonas Ogonowski, Gambling Help Service Counsellor / Community Educator

Outline THEORY • Problem Gambling: Definition, Prevalence and Impact • Introducing the Stages of Change • Case Examples • What are the pathways to Problem Gambling? • Screening and assessment tools • DMS-V criteria for Disordered Gambling • PGSI • BBGS • Dual Diagnosis and Problem Gambling PRACTICE • My practice framework • Barriers to help seeking / signs and referral • What can clients expect from GHS counselling? • Stages of Change in practice: meeting clients where they are • Summary

Gambling & Australian Culture * Queensland Household Gambling Surveys 2011-12* ** Productivity Commission 2010, Gambling, Report no. 50, Canberra.

What is Problem Gambling? QLD Responsible GamblingCode of Practice definition: “Problem gambling is characterised by difficulties in limiting money and/or time spent on gambling which leads to adverse consequences for the gambler, others, or for the community” Queensland Responsible GamblingCode of Practice, September 2012 Version 4

DSM-VDiagnostic Criteria for Disordered Gambling A. Persistent and recurrent maladaptive gambling behaviour as indicated by four (or more) of the following : • Is often preoccupied with gambling [e.g., preoccupied with reliving past gambling experiences, planning the next time you will play or thinking of ways to get money to gamble] • needs to gamble with increasing amounts of money in order to achieve the desired excitement • has repeated unsuccessful attempts to control, cut back or stop gambling • is restless or irritable when attempting to cut down or stop gambling • gambles when feeling distressed (e.g., feeling helplessness, guilt, anxiety or depression) • after losing money gambling, often returns another day to get even (“chasing” one’s losses) • lies to your family members, therapist, or others to conceal the extent of involvement with gambling • Has jeopardized or lost a significant relationship, job, educational or career opportunity because of gambling • Relies on others to provide the money to relieve a desperate financial situation caused by gambling B. The gambling behaviour is not better accounted for by a manic episode Adapted from the American Psychiatric Association Diagnostic Criteria from the DSM V May 2013 (Category: Addiction and Related Disorders. (In DSM IV: Substance-Related disorders) Disordered Gambling is the only behavioral addiction in this category.)

The Gambling Continuum* *Adapted from Productivity Commission 1999, Australia’s Gambling Industries, Report No. 10

Problem Gambling and Impact • Based on the 2011-12 Queensland Household Gambling Survey: • 0.48% of Queensland’s adult population are problem gamblers and • 1.9% of Queensland’s adult population can be categorised ‘moderate-risk’ gamblers. • Employing population data from the Queensland Government Statistician’s Office and the Australian Bureau of Statistics and employing these prevalence rates. Can estimate: • 18014 of Queensland adults are problem gamblers • 71302 of Queensland adults are moderate risk gamblers • The Productivity Commission estimate that problem gamblers are responsible for around 40% of total EGM expenditure (PC, 2010). • The harms associated with problem gambling include: • suicide, • depression, • relationship breakdown, • job loss, • bankruptcy and crime.

Young men and gambling risk While 16 per cent of the Queensland adult population were 18–34 year-old males, this group made up: • 27 per cent of the low risk gambling group • 30 per cent of the moderate risk gambling group • 44 per cent of the problem gambling group. Young men aged 18–34 years were over-represented in the low risk, moderate risk and problem gambling groups.

Time series of gambling group estimates (Queensland adult population) Percentage estimates 200103–0406–0708–092011–12 Non-gambling 15.1% 19.7% 24.7% 25.3% 26.2% Recreational gambling 73.2% 72.4% 67.3% 68.0% 66.3% Low risk gambling 8.2% 5.3% 5.7% 4.7% 5.2% Moderate risk gambling 2.7% 2.0% 1.8% 1.6% 1.9% Problem gambling 0.83% 0.55% 0.47% 0.37% 0.48% Total 100% 100% 100% 100% 100% Queensland Household Gambling Surveys 2001, 2003–04, 2006–07, 2008–09 and 2011–12 Free online http://www.olgr.qld.gov.au/__data/assets/pdf_file/0018/251136/Queensland_Household_Gambling_Survey_Report_2011-12.pdf

With up to an estimated 5 million Australians impacted by problem gambling*, this means that: More than 1 in 5 of your clients could be impacted in some way by problem gambling * http://www.problemgambling.gov.au/facts/

Effects of Problem Gambling Vocational: absenteeism, poor concentration, risk of work related accidents Personal: Health Problems = stress, depression, mood swings impulsive behaviour – Suicide Financial: debts, selling/pawning own and others property, borrowing from family and friends Spending all pay in a day Interpersonal: arguments, marriage/relationship problems, social isolation (losing friends), no time for partner and children, frequently away from home, lying about important issues Homelessness Legal: criminal activities, fraud, embezzlement, stealing

Stages of Change Model – meeting your client where they are (Prochaska, Norcross and DiClemente, 1994)

Case Examples See handout

Joan Joan is a 62 year old female. She has a daughter 40 and twin sons 38. She has been playing the pokies recreationally for about 20 years. Recently, Joan and her husband Bill have moved from Rockhampton to Brisbane to retire and to be closer to their grandchildren. However, Bill has recently been diagnosed with Parkinson’s disease which limits his mobility. Joan has spoken to you and during the conversation reveled that she has concerns that her gambling is becoming “out of control”. Additional Case Study information High anxiety evident. Joan’s spending on the pokies has gradually increased over the past 6 months since they have moved and now it is not uncommon for her to spend between $200 and $400 on the pokies at least 2 times per week. Joan has a history of anxiety and depression, diagnosed after the birth of her twin sons. She had treatment with a psychologist for about 5 sessions. Joan and Bill had an active social life in Rockhampton before Bill was diagnosed with Parkinson’s. Joan is socially isolated in Brisbane and has not told anyone, including her husband or children about her problem. Joan feels extremely guilty and ashamed of her behaviour and about lying to her husband about finances. Joan reports that Bill was verbally abusive to her and the children throughout their marriage and is fearful of his reaction.

Sam Sam, a man in his mid-forties, is a husband and father of two children. Sam started playing cards in his teens, Became involved in betting on horses and has ended up gambling at the casino. Although Sam has at times found himself in financially tight situations, such as having lost the money he was to have used to pay his bills, these occasions have been few and far between. Sam’s gambling was basically okay until the last couple of years, when a casino opened up near his home. Increased access provided Sam with more opportunity to sharpen his blackjack skills, an opportunity he seldom avoids. Sam’s gambling annoys Jen, Sam’s wife, and the children. Jen’s frustration peaked the day she told him to get some help or leave the family. Sam’s employer is also concerned about Sam’s gambling and its possible effect on work performance. Sam has considered gambling counselling services, but does not know if he belongs there and is reluctant to quit gambling. Given his happy-go-lucky nature, he doesn’t really see it as a problem.

Josh Josh is a 22 year old apprentice chef and started gambling at the age of 18 when his mother introduced him to gambling. During this occasion he had a big win on the pokies of about $3000. During high school and throughout his teenage years, Josh experienced extreme problems with bullying and self-esteem. He stated gambling regularly due to the fact that he had a positive first experience with gambling and was always chasing that big win again. Also, he used gambling and drinking as a coping mechanism for his social “awkwardness” and the pokies proved a refuge for his loneliness. Just before his 20th birthday he decided to seek help and gain assistance for his problem gambling. This treatment was successful and resulted in a reduction in his gambling and drinking. The counselling also assisted with issues around self-esteem, and as a result Josh developed better social skills and began engaging with peers and developing new friendships. Eventually, he met a girl and they moved in together. However, 8 months into their relationship they broke up and Josh decided to move to the Gold Coast for a new start. The new apartment that he moved into is within walking distance from the local club, plus his new flat mate likes to gamble regularly. Since moving to the Gold Coast Josh has experienced a rapid increase in his gambling expenditure, and feels he is losing control again.

Megan Megan is 35 years old and works part-time at the local RSL as a waitress. She has 2 children aged 12 and 7. Since moving from New Zealand 4 years ago, she has lived in a series of short term rental accommodations. Recently, she separated from her partner of 10 years. She feels that at times she struggles to pay bills and provide for her children both financially and emotionally. Megan reports she experienced loneliness when she moved to Australia and managed this in part, by attending bingo at the club with her neighbor, Beth. Sometimes in the break from bingo, Megan and Beth would play the pokies, and on one occasion Megan won a $10000 jackpot. After the win, Megan visited the club more often and frequently spent more dollars and time than she planned. Eventually, her partner Mick expressed concern then anger about the gambling. Although Megan felt guilty and tried to stop, the gambling continued. When Mick lost his job, money and free time became more difficult to access. Megan decided to make some changes.

Megan (continued) • Megan and Mick made changes to banking so that most of the money was difficult to access, but Megan had a little money each week to spend on herself. • Megan and her younger daughter joined play group and made some new friends. • Megan started helping at her older daughter’s school, with tuck shop and reading. • Some of the school mum’s invited Megan to join there netball team. • Megan and Mick upgraded their computer so she could Skype family and friends in NZ, since then Megan’s sense of exclusion from family has improved. • Megan enrolled in a TAFE course and found work at the RSL, giving her her own income and new social connections. • Eventually Mick found a new job, and financial pressure reduced. Since the breakdown of her relationship, Megan is back in control of all of her money and feels nervous about this. She is concerned that she can no longer afford her rent and will need to move, but she has no money for bond. Megan has started remembering how good it felt to win the jackpot and is fantasizing about winning enough to bring mum over from NZ to help out.

What are the Pathways to Problem Gambling ? Following a literature review, Alex Blaszczynski and Lia Nower (2002) concluded that current explanatory theories did not adequately account for multiple biological, psychological and ecological variables contributing to the development of problem gambling. In response, they advanced The Pathways Model to integrate the complex array of biological, personality, developmental, cognitive, learning theory and ecological determinants of problem and pathological gambling. Problematic patterns of gambling develop through 3 different pathways • Behaviourally conditioned (Pathway #1) • Emotionally vulnerable (Pathway #2) • Antisocial / Implulsivist (Pathway #3)

DICE GAME I need a volunteer!

The Pathways Model • ECOLOGICAL FACTORS • Increased availability • Increased accessibility Pathway #1 • CLASSICAL AND OPERANT CONDITIONING • Arousal / excitement • Subjective excitement • Physiological arousal • Cognitive schemas • Irrational beliefs • Illusion of control • Biased evaluation • Gambler’s fallacy • HABITUATION • Pattern of habitual gambling established • CHASING • Chasing wins, losses • Losing more than expected PROBLEM AND PATHOLOGICAL GAMBLING Fig 1. Integrated Model of Problem Gambling (Adapted from, Blaszczynski & Nower, 2001).

Pathway #2 • ECOLOGICAL FACTORS • Increased availability • Increased accessibility • EMOTIONAL VULNERABILITY • Childhood disturbance • Personality • Risk taking • Boredom proneness • Mood disturbance • Depression • Anxiety • Poor coping / problem solving • Life stresses • Substance use • BIOLOGICAL VULNERABILITY • Biochemical • Serotonergic • Noradrenergic • Dopaminergic • Cortical • EEG differentials • CLASSICAL AND OPERANT CONDITIONING • Arousal / excitement • Subjective excitement • Physiological arousal • Cognitive schemas • Irrational beliefs • Illusion of control • Biased evaluation • Gambler’s fallacy • HABITUATION • Pattern of habitual gambling established • CHASING • Chasing wins, losses • Losing more than expected PROBLEM AND PATHOLOGICAL GAMBLING Fig 1. Integrated Model of Problem Gambling (Adapted from, Blaszczynski & Nower, 2001).

Pathway #3 • ECOLOGICAL FACTORS • Increased availability • Increased accessibility • EMOTIONAL VULNERABILITY • Childhood disturbance • Personality • Risk taking • Boredom proneness • Mood disturbance • Depression • Anxiety • Poor coping / problem solving • Life stresses • Substance use • CLASSICAL AND OPERANT CONDITIONING • Arousal / excitement • Subjective excitement • Physiological arousal • Cognitive schemas • Irrational beliefs • Illusion of control • Biased evaluation • Gambler’s fallacy • BIOLOGICAL VULNERABILITY • Biochemical • Serotonergic • Noradrenergic • Dopaminergic • Cortical • EEG differentials • IMPULSIVE TRAITS • Neuropsychological • ADHD • Impulsivity • Anti-social behaviour • Substance abuse • HABITUATION • Pattern of habitual gambling established • CHASING • Chasing wins, losses • Losing more than expected PROBLEM AND PATHOLOGICAL GAMBLING Fig 1. Integrated Model of Problem Gambling (Adapted from, Blaszczynski & Nower, 2001).

Behaviourally Conditioned • No pre-morbid psychopathology • Problem Gambling develops through; • Learning theory • Operant reinforcement • Positive and negative • Classical conditioning • Symptoms such as preoccupation, chasing losses, depression, anxiety and substance abuse are consequences not causes of gambling. • More motivated to seek treatment and compliant, benefiting from brief interventions including psychoeducation and basic cognitive therapy designed to correct irrational beliefs.

Emotionally Vulnerable • Predisposing psychological vulnerability • depression, anxiety, substance dependence, history of suicidal thinking or behaviour and deficits in ability to cope withstress • Affect-regulation • Gambling motivated by a desire to modulate affective states and/or meet psychological needs • Gambling provides emotional escape through dissociation, mood alteration and narrowed attention • Influences selection of gambling modes • Avoidance, passive aggressive behaviours and maladaptive coping strategies • Requires more extensive psychotherapeutic CBT interventions • such as stress management, problem solving skills, enhancing self esteem and self -efficacy and therapy directed towards resolving intra-psychic conflicts

Antisocial / impulsivist • Defined by presence of neurological or neurochemical dysfunction, in addition to the emotional, biological and social learning vulnerabilities. • Family history of PG • Early onset and more severe levels of gambling • History of suicidal ideation • Narcissistic traits • Distinguished by features of; • impulsivity which are aggravated under pressure and in the presence of negative moods • antisocial personality disorder • attention deficit disorder (ADHD) • Inability to delay gratification • Display a broad spectrum of behavioural problems which include substance abuse, low tolerance for boredom, sensation seeking, criminal behaviours and poor interpersonal behaviours

Screening and assessment tools Disordered Gambling (DSM-V) Problem Gambling Severity Index (PGSI) Brief Bio-Social Gambling Screen (BBGS)

What is the PGSI? • The PGSI is a measure of problem gambling severity that consists of nine items, four of which assess problem gambling behaviours, • How often have you bet more than you could afford to lose? [Bet] • How often have you needed to gamble with larger amounts of money to get the same feeling of excitement? [Tolerance] • How often have you gone back another day to try to win back the money you lost? [Chase] • How often have you borrowed money or sold anything to get money to gamble? [Borrowed]) • and five that assess adverse consequences of gambling. • How often have you felt you might have a problem with gambling? [Felt problem] • How often have people criticized your betting or told you that you had a gambling problem, regardless of whether or not you thought it was true? [Criticized] • How often have you felt guilty about the way you gamble or what happens when you gamble? [Felt guilty] • How often has your gambling caused you any health problems, including stress or anxiety? [Health problem] • How often has your gambling caused any financial problems for you or your household? [Financial problem]).

Brief Bio-social GamblingScreen (BBGS) Three questions for identifying gambling problems: 1. During the past 12 months, have you become restless, irritable or anxious when trying to stop/cut down on gambling? Yes/ No 2. During the past 12 months, have you tried to keep your family or friends from knowing how much you gambled? Yes/No 3. During the past 12 months, did you have such financial trouble that you had to get help from family or friends? Yes/No Gebauer, L., LaBrie, R. A., & Shaffer, H. J. (2010). Optimizing DSM-IV classification accuracy: A brief bio-social screen for gambling disorders among the general household population. Canadian Journal of Psychiatry, 55(2), 82-90.

Comorbidity and Problem Gambling • Problem gambling can exist with other types and levels of harm. • Problem gamblers exhibit a greater likelihood of engaging in other health compromising behaviours. • 30-60% substance dependence or abuse • 30-70% nicotine dependence • 10-40% major depression • 20-60% anxiety disorders

DFV & Problem Gambling • The relationship between problem gambling and family violence presents in various forms; • Individuals with gambling problems perpetrating FV • Individuals with gambling problems who are or have been the victim of FV

Individuals with gambling problems perpetrating FDV • To date, research into this link has been limited. • However, it is estimated that 15 to 20% of pathological gamblers (or those with severe gambling problems) express anger toward family members and may even physically or verbally abuse their spouses. • The rates for emotional abuse could be as high as 30%, depending on how it is defined (Blaszczynski, 2000). • Likewise, in the US; • between one quarter to one half of spouses of compulsive gamblers in the US were said to be victims of abuse (US National Gambling Impact Study,1999)

PRACTICE Working with clients impacted by problem gambling.

Interventions What does the research say? • CBT • “while cognitive behavioural therapy has the most empirical support, no one style of intervention is necessarily best practice” (Productivity Commission, 2010) • Pharmacotherapies • Anti-depressants • Person-centred therapy • Gambler’s anonymous • Motivational interviewing • Tran-theoretical model • Solution focussed therapy • Eclectic / integrative approaches Tasmanian Department of Health and Human Services (2010)

My practice framework • Underlying foundation of a good therapeutic relationship. • Beginning with Carl Rogers’ accurate empathy, unconditional positive regard, and congruence, more recent common factors research suggests a therapeutic relationship and client’s expectations are influential on the success of therapeutic outcomes (Constantino, Arnow, Blasey, & Agras, 2005; Blow, Sprenkle, & Davis, 2007). In working with clients I may utilize and draw from: • Motivational interviewing • Solution Focused Approach • Cognitive Behavioral Therapy (CBT) • Schema therapy

Schema Therapy • Schema Therapy (ST) is an integrative psychotherapy, developed by Jeffrey Young in the 1980s, drawing on CBT, Gestalt, and emotion focused approaches. • Young worked with Aaron Beck in Philadelphia (Young, Beck, & Weinberger, 1993), was interested in the nonresponders to, and relapsers from, cognitive therapy. • There is growing evidence for the effectiveness of ST in treating clients who have a variety of mental health and personality difficulties* • The goals of Schema Therapy are: 1) help clients to stop using maladaptive coping styles 2) get back in touch with their core feelings 3) Reduce self-defeating schemas 4) get their emotional needs met in everyday life. 4 healing mechanisms: • “Limited” reparenting, • Emotion-focused work (involving imagery and dialogues) • Cognitive restructuring and education, and • Behavioural pattern breaking. Through blending the below strategies for change, clients develop a healthy adult mode, which leads to a greater ability to attain emotional stability, goal-directed behaviour, mutually affirming relationships, and general well-being. *Masleya, Gillandersb, Simpsonc & Taylora (2011) A Systematic Review of the Evidence Base for Schema Therapy. Cognitive Behaviour Therapy Volume 41, Issue 3, 2012 pages 185-202.

Help seeking 40% of problem gamblers in Queensland wanted help for their problem gambling 17% of problem gamblers had tried to get help for problems related to their gambling Queensland Household Gambling Survey, 2011-12

Help Seeking Barriers • Primary reasons gamblers do not seek professional help; • The social stigma, shame and embarrassment associated with having a problem • Denial of a problem • Believing they can handle it themselves without formal treatment. (Pulford et al.2009).

Reasons for not seeking help n=94 The column total is greater than 100 because people could endorse more than one reason. (Davidson & Rogers, 2010)

Reasons for not seeking help Reasons for seeking help n = 31 The column total is greater than 100 because people could endorse more than one reason. (Davidson & Rogers, 2010)

Self-Referral Process Referral Self –referral to GHS • Sources: referrals from local gaming venue staff, GPs, counsellors, psychologists and various other community support services This is why your role as a helping professional is so important

What signs have you noticed in your work with clients? What signs might you look out for?

Signs of Problem Gambling - financial Some common financial warning signs that someone may have a problem with gambling include: Money missing from bank accounts, wallet/purse or money jar Household items and valuables missing Regularly short of money even though they earn a wage Borrowing money on a regular basis Having many loans at the one time Being secretive about financial records or payslips Unpaid bills/disconnection notices Lack of food in the house Gambling Help Online

Signs of Problem Gambling - behaviour When someone develops a gambling problem, there are often noticeable changes to their mood and behaviour, including: Becoming withdrawn from others/family events Performance at work is being affected Seeming worried, agitated or upset for no apparent reason Reporting feeling hopeless, depressed, frustrated or suicidal Changes in personality - sleeping, eating, or sexual relationship patterns Controlling and/or manipulative behaviour Using threats, lies or charm to manipulate others

Signs of Problem Gambling - time Some common time-related signs that could indicate someone has a problem with gambling include: Spending more and more time gambling Being secretive about unexplained absences Often being late for commitments Over-using sick days and days off Taking an unusual amount of time for simple tasks (e.g. taking two hours to get the paper from corner store). Gambling Help Online

If my client or someone I know may have a gambling problem how do I proceed? • It is very important that your remember to: • Be respectful • NOT DIAGNOSE! • Do not label them as having a ‘gambling problem’ • Try not to use the word “problem” as it refers to their gambling • Be sensitive to the cues and indicators of problem gambling behaviour • Respond appropriately with referrals to your local Gambling Help Service • Suggested intervention; • General intervention (less specific) • “Some people may experience difficultly controlling their gambling and there are places where you can get help, ask me if you want any more information” • Specific intervention (useful for clients that you may have a good relationship with) • Name the observed behaviours • Use open ended questions • For example “ You mentioned hitting the machine when you lost, tell me about what is happening for you ?” • “You told me you were at your local pub every day this week, is that something that concerns you?”

What can clients expect from GHS counselling? Counselling Help for People Experiencing Problems with Gambling • Enhance motivation and increase self-efficacy • An increased awareness of the triggers for their gambling behaviour • Improved communication skills • Emotional management skills • Life skills (eg. Problem solving/ money management) • Assistance with self exclusion • Relapse prevention • Support for family, friends and venue staff

Counselling Help for Family and Friends What can clients expect from GHS counselling? • Emotional Help and Support • Strategies to reduce distress/stress/anxiety/depression • Self-care • Education • Increase understanding of problem gambling behaviours • Relationship Issues • communication skills • assist family members and friends to make important decisions about thier relationship • Legal Help • Referrals to protect family income, assets and explore options • Financial Help • Referrals to protect family income, assets and explore options

requirements for intervention in problem gambling The APS suggests the following as minimal requirements for intervention in problem gambling: • Counselling or psychological intervention must be competently delivered by appropriately trained clinicians. • Only an intervention whose effectiveness is supported by empirical research should be used. • The most appropriate minimal and non-intrusive approach should be applied in the first instance. • Comorbid primary conditions must be diagnosed and treated accordingly. • Relapse prevention strategies should be included to help avoid recurrence of problems. APS

Stages of Change Model – meeting your client where they are (Prochaska, Norcross and DiClemente, 1994)

Problem Gambling: Prevalence, Screening, Assessment and Intervention